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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J8ffic~;;rJ:1pmas ManifM~ij~NAME
COUNTY Dutchess
CITYfTOWN '^'appinger
DISTRICT . .
~~~I~~~R1368
NUMBER 92
1 . A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 059 66 2498
2. RESIDENCE A. M~TATE) B. F(E~jin
C ~~5CK ONE 0 CITY JtJ TOWN 0 VILLAGE
SPECIFY Sunderl:md
o STREET ADDRESS 279 Amh8rit Road, Apt. 21 ZIP 01375.9453
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESoiJ NO
3. A AGE 27 38 DATE OF BIRTH McOe /~? / ~ 1
4. EMPLOYMENT
A. USUAL OCCUPATION Graduate Student
B. TYPE OF INDUSTRY OR BUSINESS Education
5. PLACE OF BIRTH ~OO ~
. 1 C TRY IF NOT USA)
6 FATHER
A NAME JamCG Mangarillo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jacqueline Watson
8 COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OFPREIlIOUS.MARRIAGESWIiICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
8 HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Julie ~phanie M~~SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE l\IIann::lrillo
(OPTIONAL. SEE REVERS!!) :::I
D. SOCIAL SECURITY NUMBER 128-64-1229
12. RESIDENCE ANY(STATE) B.D~~ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \^' .
SPECIFY . . applnger
o STREET ADDRESi60 Hillcrest r.nllrt ZIP 1 ? ~!=ln
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olJ NO
~TH -1)~AY -1 ~gJ
13. A. AGE 27
14. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Civil Engine8r
B. TYPE OF INDUSTRY OR BUSINESS Engineering
15 PLACE OF BIRTHC?ciW s9M:~&~Sl!<NE6rPs~ie
16. FATHER
A. NAME Steven Lance Munoz
B. COUNTRY OF BIRn-i I S A
17. MOTHER
A. MAIDEN NAME Irene Caroline Grace Leckie
B. COUNTRY OF BIRTrScotland
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A.NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 4TH
d belief that the information I provided is true an
o
o
o
23. SUBSCRIBED AND SWORN TO/AFF MED BEFORE
SIGNATURE OF TOWN OR CITY CL RK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
DATE
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
07/? 1/?00R
by New York Domestic
MONTH
MONTH
YEAR
YEAR
07
22
2008
09
19 2008
SA
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY 1).) 'T'c.t4l6S'S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~VILLAGE OF
09
o'g
29. OFFICIANT
NAME (PRINT)
'S''J
TITLE
DATE
nnJ.1.QR Im/?nM\
28. PLACE WHERE MARRIAGE OCCURRED
? I\:s fb R-
f{/~/o~
,
tv
STA E
~
SPECIFY W k ;?PI,.) C,t:f'te5